It’s that time of the year again…the time where stress is high and people are struggling to get everything complete before the potential of summer, family vacation, or maybe just the accumulation of enough vacation days to actually take that true holiday you have been dreaming about since December. So how do you make ends meet? There are not enough hours in the day to finish everything you need to do. You know that you should be getting at least 7 or 8 hours of sleep a night, but you just need to finish writing this last page of a paper or draft a couple more emails. So maybe you work through the night a couple times, you’ll catch up on your sleep over your upcoming holiday, right? Wait… what holiday?

With the average American recorded as getting 6.8 hours of sleep per night, this number seems a bit too good to be true. The reality is that young professionals between the ages of 18-24 get less than the recommended hours of sleep; however, it is unclear how much less sleep people are truly getting. Furthermore, it depends on how we define sleep. Does this 6.8 hours measure quality sleep – true REM (rapid eye movement) sleep, when you’re passed out displaying a steady stream of drool or with the accompanying symphony of snores (whichever is your preference)? Or does this figure include all sleep, whether REM or those evening power naps we allocate to ourselves when under extreme pressure? It may be reasonable to assume that our sleep patterns often do not meet the minimum requirement for healthy living.

As demonstrated in a study conducted by Virgin Impulse Institute, 76% of the U.S. workforce is tired most weekdays. An additional study published in the Journal of Occupational and Environmental Medicine highlights that “the cost of fatigue-related productivity is estimated at $1,967 per employee annually.” It is clear that lack of sleep is a recognized hazard, but it’s basically accepted as the norm in American society.

As a little reminder of the impact of sleep deprivation on one’s health and well-being, please watch this short video entitled, “What if you stopped sleeping”:

So let’s break it down. Why are we not getting enough sleep?

…Pressure at work?

…School?

…Financial concerns?

…Kids?

…Health problems?

With the amount of pressure and stress that the average American is exposed to on a daily basis, it shouldn’t be much of a shock that quality sleep is rare. Sleep and stress are closely correlated. Numerous studies have shown that lack of sleep leads to higher levels of stress, and simultaneously, increased stress directly impacts one’s ability to sleep, creating a vicious cycle that is not easily broken.

Ever heard of someone falling asleep in response to stress and anxiety? That response can be categorized as a type of “learned helplessness.” According to this article in The Atlantic, “if, at a very early stage in development, a living thing comes to understand that it is helpless in the face of the world’s forces, it will continue to perceive a lack of control, and therefore actually become helpless, no matter if the context changes.”

But wait! It turns out that the person isn’t helpless per se, but rather he or she is sleeping in order to deal with the stress. Because sleep allows us to better process and remember our experiences, going to sleep following a stressful event will essentially “protect” that memory and response.

Think about how children are always napping. They’re in the midst of constantly learning from this big world around them, not to mention they have a small,“short-term memory storage space.” Thus to consolidate their memories for future use, they have to nap more.

It is unrealistic to assume that every American will be able to get their full 8 hours of sleep every night (even including daytime naps); however, there are some easy steps we can all take to try to manage our stress and sleep.

Here are some tips from the Mayo Clinic for getting a more restful sleep:

Stick to a consistent sleep schedule…even on non-work days

Exercise during the day (but no closer than three hours to bedtime)

Eat lighter evening meals

Be wary of consuming caffeine, alcohol, and nicotine too close to bed

Have a relaxing bedtime ritual

Avoid long daytime naps

And here are some extra tips for good measure:

If you’re stressed out or still have some energy to dispel before bed, try journaling

Turn off electronics at least an hour before you plan to sleep

And most importantly, remember that whatever work you’re doing late at night is not worth your health and can probably wait until the morning

We all love our smartphones – I mean, why wouldn’t we? These days you can do everything from order takeout to request personalized cab service with a tap of your screen. The average American spends 58 minutes on their phone per day, with only 26% of total time spent actually speaking on the phone. (Experian Marketing Services) The remainder of the time is spent texting or browsing the multitude of additional functionalities of our phones.

Fortunately, thousands of smartphone applications intended to help people maintain and/or improve their health are available for free or for instant purchase on mobile platforms like Apple’s iOS and Google’s Android operating systems. Want to do some yoga on the go? There’s an app for that. Or how about trying to find the nearest farmer’s market? Yep, they have that, too. Worried that health bar isn’t good for your diet? Scan the barcode with your phone to learn the sugar content, calories, and healthy alternatives, while also tracking your weight loss. But do these apps really address pressing public health issues? Let’s take a closer look at arguably the most significant public health problem of the 21st Century – the obesity epidemic.

Obesity continues to remain a public health concern for America. According to the CDC, it is estimated 69.2% of adults over 20 are overweight, and 35.9% of those adults are obese. Monitoring calorie intake, increasing consumption of fruits, vegetables, and water, and increasing physical activity are all strategies used to encourage weight loss. And you guessed it – there are apps to help high-risk and diagnosed individuals with all of these things. However, there is still the question of whether your smartphone can actually help you stay or get healthy.

A randomized control trial conducted last year found that those assigned to a weight management intervention via a smartphone app adhered to their program significantly longer (92 days) than their website (35 days) and diary (29 days) counterparts. (Carter, et. al., 2013) The smartphone group also lost a larger amount of weight over the course of six months (10.1 pounds) compared to the website (6.4 pounds) and diary (2.3 pounds) groups.

These apps seem promising at encouraging a healthy lifestyle. Yet, the wellbeing of an individual extends beyond entering the calorie content of those french fries they just ate. Mobile applications are also becoming more integrated in the hospital setting. Medical applications, such as DrawMD, allow patients to visualize their surgical procedure through comprehensive drawings. Through the VaxNation app, patients can enter their birth date and previous vaccination history to receive CDC recommendations for future vaccinations. Patients may also monitor prescription history and receive reminders about when they need to renew their medications. There are even applications being developed that could potentially diagnose serious conditions, such as rheumatic heart disease, without ever requiring the patient to set foot in a hospital.

The Food and Drug Administration (FDA) is beginning to explore the legitimacy and safety of these applications. In September of last year, the FDA announced that the department would begin to “regulate applications and gadgets that work with smartphones to take medical readings and help users monitor their health.” (Huffington Post, 2013) Regulation would be focused on select mobile applications that serve complex functions ranging from apps that “turn smartphones into devices, like a heart monitor, to medical attachments that plug into smartphones.”

The FDA estimates that by 2015, 500 million smartphone users worldwide will use some type of health application on their smartphone. (FDA). With so many cell phone users around the world, it is no question these mobile applications will have huge impacts on the well being of others. Will we see the day when you can diagnose HIV infection from a cell phone? While that remains to be seen, one thing is for certain – the world is in the midst of a technology revolution and within that, the potential for a health technology revolution as well. So the next time you decide to spend countless hours trying to score another point in Flappy Bird, why not check out a mobile health app?

]]>https://publichealthis.wordpress.com/2014/04/26/do-smart-phones-help-us-stay-healthy/feed/0Untitled3chlfellowsUntitled2Untitled3We’re Not as Peaceful as We Think: Re-examining Violencehttps://publichealthis.wordpress.com/2014/04/17/were-not-as-peaceful-as-we-think-re-examining-violence/
https://publichealthis.wordpress.com/2014/04/17/were-not-as-peaceful-as-we-think-re-examining-violence/#respondFri, 18 Apr 2014 05:12:36 +0000http://publichealthis.com/?p=682Peace the old fashioned way

Language is a pretty fickle thing. Over time, some words can get so charged that we feel like we have to tip-toe around them. No one likes to say a school is “failing” their students — instead, it’s “underperforming.” Other words can get so mired in one definition that it makes the word limiting. Take the word “violence.” Immediately, most of us think of something like a fight, maybe a beating. The brutality of war probably comes to mind, too.

And there’s a reason that comes to mind – there’s usually a clear “perpetrator” and an obvious “victim.” Our brain is pretty lazy, so we like these easy-to-visualize ways to think about things. And simply put, we can usually think of peace as the absence of violence — peace activists are usually protesting war, police beatings, or even violent video games, right?

Like we said, language can make some words kind of limiting. About 45 years ago, Norwegian peace researcher Johan Galtung noticed that our definition of violence wasn’t doing anyone any favors. Galtung proposed expanding the definition of violence to mean anything limiting a person’s ability to reach their potential. Let’s use the city of Oakland, CA, and its neighbors to make a point – according to the Alameda County Public Health Department, a baby born in the Castlemont neighborhood in East Oakland will live almost 12 years less than a child born in the much more affluent community of Piedmont. Less than ten miles separate these neighborhoods, but it is night and day. Coinciding with these trends are dozens of indicators; East Oakland also has some of the worst education opportunities, job opportunities, public safety ratings, and community opportunities. Not surprisingly, there are way more liquor stores and way fewer grocery stores in East Oakland, too. In contrast, Piedmont has the seventh best school district in the state of California, and in 2000 had a median family income of around $150,000, or ten times the federal poverty limit in the same year.

The American Public Health Association and California Endowment’s campaign against structural violence.

So why bring this up when talking about violence? Because if we use violence to mean physical harm, then we can say Oakland just needs more police, and then there will be peace. But thinking this way is blinding us to some of the most glaring issues. Everyone should be able to live to at least 80 years old; if something is stopping you from living that long, and that something is preventable, then that is violence too. Couldn’t afford health care, and you never got to see a doctor before diabetes took your leg? We wouldn’t normally think of that as violence, but we should. Live in an area where you can’t get fresh fruits and vegetables to make sure your kids grow up healthy? Violence.

It doesn’t have to be one person attacking another — when unequal medical, education, and income access are built into the structure, it is what Galtung labeled “structural violence.” Without this addition to how we think about violence, some pretty limiting environments can still be thought of as “peaceful.”

We need more than “law and order” societies that focus on personal violence and ignore structural violence. That’s because limiting someone’s potential is “violence,” regardless if it’s due to gang violence or a lack of food access.

Unfortunately, it’s easier to measure personal violence — gun-related deaths, drunk driving accidents, and war casualties can be tallied up pretty easily. Structural violence can be harder — “death by lack of access to resources” won’t show up on many death certificates. But unless structural equity is persistently and deliberately identified and pursued through policy change and social action, structural inequity will remain a part of our communities and will increase. We need to reshape how we look at violence, and not content ourselves with stopping personal violence. It may be uncomfortable, but we need to acknowledge that our cities and institutions can be just as violent as any shooting or robbery.

So, how do we live in peace? The Alameda County Public Health Department, UC Berkeley, and over 40 community organizations are teaming together to form Building Blocks for Health Equity. This collective is tackling the structural violence in Oakland head-on, to “create conditions where every child has an equal chance at a healthy and fulfilling life.” This emphasis on the conditions that promote health, not just individual actors, is key to ending the structural violence that can’t be linked to one person or situation. Once we change how we look at the language of violence, we can start on the real work of bringing peace.

It’s in my ears wherever I go these days. It’s the music I dance-walk to as I buy chapstick at the drug store. It’s the music I dance-eat to at my local burrito shop. It’s the music I dance-read to on the bus. I visited Pharrell’s 24 hour music video website recently. I smiled and sang, “Clap along if you know what happiness is to you…” I might have danced, too.

The more I listen to Happy, the more I wonder: What IS happiness? Scientists acknowledge that happiness is a complex construct, meaning something different from person to person, community to community, moment to moment, and the list goes on. Still, it is interesting to try to understand what happiness means.

Validated happiness scales, with indicators such as life satisfaction, health, community, and civic engagement, begin to describe the construct of happiness. Positive psychologist, Ed Diener, asserts that happiness, or “subjective well-being,” is a combination of life satisfaction and experiencing more positive emotions than negative emotions. Martin Seligman, another lead researcher in positive psychology, divides happiness into three parts: pleasure, or the “feel good” part of happiness; engagement, or living a “good life” of work, family, friends, and hobbies; and meaning, or contributing to a larger purpose. Matt Killingsworth, a researcher at Harvard and former product manager in the software industry, recently built a smart phone application, Track Your Happiness, that enables people to report their feelings in real time. Killingsworth found that people were often the happiest when they were lost in the moment.

Despite the somewhat elusive nature of the term, happiness is important to the field of public health. Research indicates that there are positive health benefits of happiness. In a review of more than 160 human and animal studies researchers found that “happy people tend to live longer and experience better health than their unhappy peers.” Laura Kubzansky at the Harvard School of Public Health analyzed data from a study that followed 6,000 men and women aged 25 to 74 for 20 years and identified that emotional vitality – defined as a sense of enthusiasm, hopefulness, engagement in life, and the ability to face life’s stresses with emotional balance – appears to reduce the risk of coronary heart disease. Results from an eight-year study following more than 3,000 people age 60 and older living in England showed that happier people maintained better physical function as they aged, even when adjusting for potential confounders such as age, lifestyle, and economic situation. According to the American Happiness Association, people who are positive about aging live 7.5 years longer than those with less positive perceptions, a benefit that surpasses those of smoking cessation, exercise, and obesity control. Researchers at UCLA are even showing that genes of people with high levels of eudaimonic well-being, or happiness rooted in living a purposeful life, function better by keeping inflammatory gene expression low and antiviral and antibody expression high. So, what can we do to live happier, and therefore healthier, lives?

Pretty easy stuff, huh? Or maybe we should all participate in the #100happydays challenge. People who successfully completed the challenge claimed to start noticing what makes them happy every day; be in a better mood every day; start receiving more compliments from other people; realize how lucky they are to have the life they have; become more optimistic; and fall in love. That sounds pretty good to me! And, possibly best of all, if you complete the challenge you get a book with the 100 happy photos you posted during the challenge. I don’t know about you, but another picture book of my cats sounds pretty good to me!

OK, you get the point.

Although these tips may be useful and the #100happydays challenge sounds fun, being happy is not solely a product of individual effort. As Kubzansky cautions, “When you take this research out of the social context, it has the potential to be a slippery slope for victim blaming.” So the question then becomes: How can we, as public health professionals, create contexts in which people can be happy? Healthy? Free of violence, worry, and chronic stress? With smiles and laughter, fresh produce, and walkable streets?

Maybe we can learn some lessons from the small country of Bhutan, with its multidimensional Gross National Happiness (GNH) Index. The measure is rooted in the idea that the pursuit of happiness is collective, though it can be experienced personally, and is reliant on nine domains: psychological well-being, time use, community vitality, cultural diversity, ecological resilience, living standard, health, education, and good governance. According to A Short Guide to Gross National Happiness Index, “the GNH Index is meant to orient the people and the nation towards happiness, primarily by improving the conditions of not-yet-happy people.” Perhaps the GNH Index would be more useful than the Gross Domestic Product (GDP) for identifying health policies to improve happiness and health among United States citizens?

I am not quite sure where we go from here, but the data and statistics clearly show that happiness is an important construct to understand for public health professionals. I am confident that from individual level solutions to policy interventions, we will find real ways to create a more equitable world in which happiness is not such an elusive construct, but one felt and known by all.

Think for a moment about your last experience receiving healthcare. Were you at a doctor’s office? A hospital? Was it easy to get to the provider’s office? When you entered the building, how easy was it finding your doctor’s office? Was there any staff to help you? If English is not your primary language, was there anyone who asked you if you preferred to have an interpreter during your visit? How long did you wait in the provider’s office? Who were you seen by? Did you have to repeat any information to various healthcare providers during the visit? Did you feel that your visit answered all your questions? Were you appropriately sent for lab tests or were you given prescriptions that could be easily filled at the pharmacy? How would you rate this experience? Did you feel that you received the best quality of care?

In one healthcare visit, providers and hospitals are asking these very questions that get to a root piece of providing healthcare: the patient experience. Long gone is the simple rhetoric of increasing quality of care for patients. The Affordable Care Act (ACA) requires healthcare stakeholders such as doctors and hospitals to be held accountable for care that is provided to you.

Understanding how healthcare stakeholders are tracking quality improvement measures requires a bit of “Quality Measure 101.” Here is a high-level snapshot. Avedis Donabedian created the first rationale for measuring quality of healthcare in 1978. Since then, many institutions, organizations, and programs have developed quality measurements off Donabedian’s early principles that quality is “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”[1] Organizations such as the National Quality Forum (NQF) reviews, endorses, and recommends quality measures that are recognized as the “gold standard” by government agencies such as the Centers for Medicare and Medicaid (CMS) and other commercial entities adopting quality improvement projects. Other commercial projects such as the California based Integrated Healthcare Association (IHA) develops measures to standardize quality measure reporting in its highly recognized Pay for Performance (P4P) program and Value Based P4P program. IHA P4P defines measures loosely into four domains: Clinical Quality, Meaningful Use of Health IT, Resource Use, and Patient Experience.[2]

So what? Do these measures actually improve quality of care, and more importantly, patient experience? Some examples have been adopted that are proving to be promising. The Toyota Production System’s LEAN manufacturing practices are being adopted by healthcare delivery systems to reduce waste and improve healthcare value. Ultimately, revisiting and revamping healthcare process means better healthcare to the patient—to you. Safety net hospitals such as San Francisco General Hospital (SFGH) are proving that the LEAN method can work—even with limited resources in comparison to other healthcare systems that have a higher volume of commercial patients (e.g. which generally means more money flowing through the hospital).[3] Specifically referred to as Kaizen, a specific LEAN management tool that requires about a week long improvement workshop, SFGH has been using Kaizen methodologies to focus on improving value stream processes over the last two-years. The Kaizen approach has helped improve SFGH quality of care.

Looking deeper into the Kaizen process, brings up some interesting word choices. Kaizen means “good change” or “improvement” in Japanese and refers to the philosophy of continually improving processes. The process focuses on standardizing an operation, measuring the operation, gauging measurements, innovating processes to increase productivity, standardizing the new process, and continuing the cycle. Throughout the process, words like seiri (tidiness), seiton (orderliness), seiso (cleanliness), seiketsu (standardized clean-up), and shitsuke (discipline) are used.[4] The Kaizen method is thought of as a way of life philosophy and that every part of our life may have continuous incremental improvements. Looking at health improvement in this way begs the question: are quality measurements and delivery systems capturing the improvement on an individual’s total health?

One important piece of the puzzle that is missing when looking at improving quality of care is that healthcare is only one driver of people’s overall health. When looking at people’s health, we need to consider other factors such as environmental and social factors, personal behaviors, and family history and genetics. McGinnis et al[5] spoke of these drivers of health and that medical care makes up about 10-15 percent of the picture. In thinking of bold concepts, perhaps there could be a focus to use Kaizen principles that link to patient values to improve the total individual. Many patients and providers believe holistic health care is one ideology to treat the total individual in that it manages and can often prevent long term health conditions while simultaneously encouraging a connection to cultural and personal beliefs.

Kaiser Permanent’s Center for Complimentary Medicine (CCM) is a holistic health care approach promoting “harmony” through preventative care. Complimentary and preventative medicine is alive and well in the United States and continuing to gain momentum as bigger health care organizations such as Kaiser integrate and promote this level of care. At Kaiser Permanente, the Center for Complimentary Medicine (CCM) provides support to their members (and non-members) working to meet the needs of their patients, not just when they are sick, but by treating the “whole person”. The provided support encourages patients to maintain health lifestyle choices and increase their overall health and wellness. CCM’s mission is to provide personalized complementary care with an emphasis on preventive measures, pain reduction and patient education. Many people are incorporating complementary care into their lives as a way to connect to cultural and personal beliefs and manage or even prevent health conditions.

CCM recently introduced Integrative Medicine in 2012. Integrative Medicine is a combination of conventional Western medicine with complementary and alternative medicine treatments, personalized for effectively treating the individual patient, not just the symptoms or the disease. Patients receive a 1 hour consult with an Integrative Medical Physician, a 1 hour consult with a Nutritionist, a 30 minute follow up with Nutritionist and Demo Kitchen Cooking Classes. Many patients are referred to CCM through provider referrals because providers believe the preventative care model encourages healthier lifestyles, improving the health of their patients and reducing the amount of chronic disease providers treat outside of the Center for Complementary Medicine.

There is a need to re-focus and integrate care that treats the “whole person.” One method we believe could capture this is treating the individual with Kaizen methodologies in an environment such as the Kaiser Center for Complimentary Medicine. Current quality measures to improve patient experience do not necessarily target these delivery systems and metrics may not be able to truly capture the good work coming out of these centers. However, incorporating patient’s individual culture and beliefs to encourage life changes may have the biggest impact on improving people’s health. The topic of complimentary medicine as a way to improve total health and the patient experience relates directly back to the discussion about quality improvement. There is the proverbial saying that if you give a man a fish, you feed him for a day. If you teach him how to fish, you feed him for a lifetime. This concept should be the next focus in revitalizing the healthcare industry: let’s incorporate medicine that harnesses people’s values and changes people’s lives.

]]>https://publichealthis.wordpress.com/2014/03/14/what-about-the-patient-a-look-at-quality-measures-kaizen-and-complementary-medicine/feed/0pic3chlfellowsQualityLean/KaizenHarmonyPublic Health Is…Starting Conversationshttps://publichealthis.wordpress.com/2013/09/26/public-health-is-starting-conversations/
https://publichealthis.wordpress.com/2013/09/26/public-health-is-starting-conversations/#respondThu, 26 Sep 2013 16:58:59 +0000http://publichealthis.com/?p=637In the vein of starting conversations around what we eat and why, CHL Fellow Sophie Egan wrote “Stunt Foods,” the cover story of the October issue of Wired. Check it out!

What does it say about American food culture that Taco Bell’s Doritos Locos Tacos sell in record numbers? How can this trend be happening at the same time as Michelle Obama’s “Let’s Move” campaign, Burger King’s “Satisfries,” and quinoa gone mainstream?

Imagine for a moment that you are a single, 27-year-old woman with two young children, six months pregnant…and homeless. The father of your unborn child is violent and prone to abusive behavior. You are unemployed and have difficulty finding sustainable housing. You hear about a local shelter that has a vacancy for tonight – they have food and there are mats where you and your children can sleep on the floor. At 8:00 am the next morning, you are required to pick up your belongings, and head back out to the streets. You wait until 4:00 pm when the shelter opens again, only to hear that there are no vacancies tonight. The stress of being a single mother and homeless takes its toll on you, and you worry about the health of your unborn child. You are scared to seek out prenatal care because you don’t have health insurance and you are afraid of what providers will think of you. You are depressed and continue to use alcohol and drugs throughout your pregnancy.

Homeless Women and Children Have Increased Health Risk

Homelessness has become part of the life experience for growing numbers of American mothers, children, and families. According to this annual report on homelessness in the U.S., on any given night in 2010, 407,966 individuals experienced homelessness in shelters, transitional housing programs, or on the streets.[i] Of homeless families in shelters, women comprise 77.9% of adults, with nearly 1.5 million children experiencing homelessness in any given year.[ii]

Given these risks, pregnancy is a time of particular vulnerability for the children of homeless mothers. Research has found that high levels of stress during pregnancy can result in a change in the normal development of the fetus, and persistent disparities in health outcomes among minority women are associated with stress.[vi] This is a burgeoning national problem, especially when we consider the life course of pregnant homeless women, many of whom are minorities and/or substance abusers.

What is the Life Course model and what does it mean for homeless pregnancy mothers?

For those of us in public health, it’s rather obvious that the persistent health disparities faced by vulnerable populations are cyclical. Consider the fact that an African American infant born today is more than twice as likely to die within the first year of life as a White infant.[i] While there are some theories that explain this phenomenon (like weathering), we still haven’t effectively addressed the fact that African American infants are twice as likely to suffer from low birth weight, African American women are more likely to have preterm births, or why these inequalities persist for these women despite household income, educational attainment, or geographic location. But what if it’s possible that these disparities in birth outcomes are the consequences of developmental trajectories set forth by the early life experiences of a mother and her child? What if we re-worked the current framework that exists when we think about social, economic, and racial-ethnic disparities in birth outcomes to include the life course?

This is what the Life Course model is all about: the idea that disparities are the consequences not only of what happens DURING pregnancy, but more importantly what happens over the course of a woman’s life. When we think about the fact that homeless women have inadequate access to prenatal care, we need to think about what this means for the their lives and the lives of their children. This isn’t a “homeless,” “substance-abuse,” “African-American,” “poverty,” or “maternal” problem. This is a community problem. And it takes our community to work together to solve it.

Addressing the Life Course for Homeless Mothers and Children: San Francisco’s Homeless Prenatal Program

There is no one elixir to improve the life course of homeless women and their children, but if we consider where we can actually affect the life course of this vulnerable population, it begins in the womb. Unfortunately, prenatal care is not easily accessible by homeless mothers. Everyday obstacles such as bus fare, childcare, violent partners, fear, and distrust can easily come in the way of doctor appointments. Although there are innovative efforts to address these issues across the country at the local and national level, one model has shown to be particularly effective in reaching homeless women and families where they are. We want to highlight the work of San Francisco’s Homeless Prenatal Program (HPP), which provides a holistic community solution to these growing community problems.

Founded in 1989, HPP is devoted to helping and empowering women improve their life course and that of their children. The program connects homeless women to prenatal and health care services, assists them in overcoming issues of mental illness, substance abuse and domestic violence, and assistance in finding sustainable housing, employment, and job training. In doing so, HPP helps women break cycles of poverty, homelessness, and social inequality, and decrease the likelihood that their children unjustly suffer from health inequalities. Last year, the program worked with 3,500 families, and touched the lives of more than 9,000 children.[i] HPP is more than a resource for homeless women and their children- it is a community that is taking back what it means to thrive in the face of adversity. It is a community that can be a model for National-level programs.

As public health professionals, and as a greater community, we need to move beyond simply looking at pregnancy risk factors, but to early life programming and cumulative stress, racism, and traumatic life experiences over the life course. What if we could ensure that every baby was born into a healthy, safe, stress-free environment? Wouldn’t the future generations of stronger mothers and stronger babies thank us?

All photos are courtesy of the Homeless Prenatal Program’s website: http://www.homelessprenatal.org/

[i] Data in the are comprised of annual point-in-time counts and HMIS data reported throughout the year (October 2009-September 2010). Data are reported based on HUD’s definition of homelessness, which includes people in shelters and on the streets, but not those who are “doubled up” with families or friends.

Two weeks ago, the world was sent into shock upon hearing that there were bombings at the Boston Marathon. As avid long-distance runners ourselves, these bombings hit particularly close to home, and we deeply feel the pain, fear, and shock of the victims and their families.

The Boston Marathon is the world’s oldest marathon and is considered to be one of the most prestigious races, since you can only sign up if you have met its stringent time-based qualifying standards. Many runners spend years training to qualify for Boston (one of the authors included!), but not all of them are able to do so.

The Boston Marathon usually registers over 20,000 competitive runners and attracts over 500,000 eager spectators to the Greater Boston area, making it New England’s most popular sports event [1]. This year, the unexpected bomb attack turned Boston’s most inspirational event into a bloody battleground, throwing the city into complete chaos. The bombers had the intention of killing as many people as possible. The explosions left three dead and over 250 injured.

What went right on such a tragic day? Some say it’s a miracle that so many people survived. Others say they were lucky to be in a city with the nation’s best medical centers. But with a closer public health look, we realize Boston’s emergency preparedness and coordination plans made the real difference.

Within moments of the explosions, medical tents near the finish line were ready to stabilize injured runners and spectators [2]. Typically, volunteer medical personnel are prepared to address common runner conditions including dehydration, hyponatremia, muscle cramps, sunburn, and sprains and stress factors [3]. But Boston Marathon volunteers went beyond their expectations and took in patients who suffered life-threatening conditions while ambulances raced to the scene.

Photo Credit: Charles Krupa / AP

Photo Credit: David L. Ryan, The Boston Globe, Getty Images

Once ambulances arrived, patients were quickly loaded and transported to appropriate health centers. Prepared facilities include the nation’s finest: Massachusetts General Hospital, Boston Children’s Hospital, Tufts Medical Center, Brigham and Women’s Hospital and Beth Israel Deaconess Medical Center [4]. Trauma centers throughout Boston followed their emergency plans by calling in off-duty staff, bringing in physicians and nurses from other facilities, and assigning personnel to high priority cases.

Boston’s response was extraordinary. But are other cities in the country as prepared?

Here at the UC Berkeley School of Public Health, we continually push the value of preparedness and prevention. How can we plan in advance for disasters and tragedies? What systems and structures need to be in place for quick and effective responses?

“Nothing can really prepare one for the worst (all-hazards), but it’s what we train and plan for with steady precision, measured restraint, and commitment to do good in our communities and tailored to varying site specific venues,” says Michelle Heckle, Certified Healthcare Emergency Professional at Children’s Hospital & Research Center Oakland. Michelle’s role, as she describes it, is to plan the catastrophic demise of the organization and all of its people AND mitigate against it – and nobody can do this alone.

All hospitals in the US are required to have an Emergency Operations Plan (EOP) [5]. This plan is guided by the National Preparedness Goal [6], often based on The Joint Commission standards, and helps hospitals mitigate, prepare, plan, respond, and recover from emergency situations. In addition to the EOP, it is important that hospitals have a dynamic and strong incident command system (ICS) team. Heckle says that her team “consistently keeps a pulse on events occurring around the nation and learns to scale up or down quickly.”

Now we can look to Boston as a model example. Boston’s healthcare system had been long prepared for this tragedy. In 2011, the city held an emergency drill that brought together Boston police, firefighters, hospitals, and emergency medical service workers [2] to respond to a mock situation. This effort reflects the city’s long-term commitment to developing response plans directing patient care and trauma and healthcare personnel to appropriate facilities. In the past decade, health centers and emergency personnel have been sharing resources, developing strategies, and detailing action plans as groundwork for an event like the bomb attack on the Boston Marathon [4].

However, emergency response isn’t just limited to physical trauma. Ana-Marie Jones, Executive Director of the Collaborating Agencies Responding to Disasters (CARD), writes in her upcoming article in the Oakland Business Review:

“Feed your employees a steady diet of helpful stress-reducing information. Many people have negative reactions just from watching coverage of tragic events. Provide information about stress and grief counseling, and make sure they know they can call 2-1-1, crisis hotlines, and other free and confidential resources. Encourage them to sign up for local alerts from the police department. Send reminders for people to stay hydrated and to breathe deeply.”[7]

While all physical injuries have been addressed, we must remember that the situation isn’t over yet: tragedies such as the Boston Marathon have very long-lasting effects on society that affect far more than those directly injured. “The public health continuum endures after initial treatment and response as a reflection of the whole community effort,” says Heckle. Those who were injured will endure months, if not years of physical therapy. Such tragedies also cause significant mental health issues, which sometimes remain unaddressed among the injured and their loved ones. Aftermath plans must include institutional strategies to address mental health concerns that could linger for those who fell victim to the disaster.

While we were shocked to hear about the bombings in Boston, we are proud that our healthcare system, despite its flaws, was able to respond so quickly and take excellent care of the injured. Around the world runners have united to “run for Boston.” As committed runners, we are incredibly stubborn, and nothing, not even bombs, will stop us from doing what we love to do. As we look forward to lining up for our next race – which will hopefully one day be the Boston Marathon – we take comfort in knowing that in the event of a medical emergency, we will be prepared.